Provider Demographics
NPI:1649054909
Name:JIM, CORINNA A
Entity type:Individual
Prefix:
First Name:CORINNA
Middle Name:A
Last Name:JIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 E 20TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2151
Mailing Address - Country:US
Mailing Address - Phone:505-327-0293
Mailing Address - Fax:
Practice Address - Street 1:475 E 20TH ST STE D
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2151
Practice Address - Country:US
Practice Address - Phone:505-327-0293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-18
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2023-0832104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker